Immanuel's Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #10) reviewed for resident rights. The facility failed to ensure visual privacy for Resident #10, whose buttocks was left uncovered while lying in bed when LVN A left resident's care area for 10 minutes. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of hazards as was possible for one of six residents (Resident #15) reviewed for accident hazards. The facility failed to ensure a pair of scissors and nail clippers were not on Resident #15's bedside table on 07/08/2026. These failures could place the residents at risk of avoidable accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain respiratory care including oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen for two (Resident #13 and #15) of six residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #13's nebulizer mask was bagged in a plastic bag.2.) The facility failed to ensure that Resident #15's oxygen tubing/nasal cannula was bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #10) of 6 residents, reviewed for infection control. LVN A failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precautions. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for one (Resident #1) of five residents reviewed for comprehensive care plans. The facility failed to complete a comprehensive care plan within 21 days of Resident #1's admission to the facility. This failure could place residents at risk of not receiving effective, person-centered care, and maintaining his or her highest practicable quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (Resident #1) of three residents reviewed for abuse. The facility failed to implement their abuse policy and procedure after an allegation of abuse was made regarding Resident #1. After making an allegation of verbal abuse by the Administrator, the Administrator confronted Resident #1 regarding the allegation. This failure could place residents at risk of abuse due to facility failure to follow their policy and procedures for abuse.

Inspectors wroteBased on interview and record review, the facility failed to, in response to allegations of abuse, have evidence that all alleged violations were thoroughly investigated for one (Resident #1) of three residents reviewed for abuse. The facility failed to thoroughly investigate an allegation of verbal abuse reported by Resident #1. This failure could place residents at risk of abuse due to facility failure to fully investigate allegations for abuse.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Res#1, Res#2, Res#3 of 4 residents reviewed. The facility failed to ensure that the nursing home staff provided adequate documentation for who received offsite HHD treatments at an ESRD unit. These failures could place dialysis residents at risk for not having adequate documentation of dialysis care in result in a decline in health and quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the freezer area on 06/09/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 06/09/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 06/09/25. 4. The facility failed to ensure an expired item in the refrigerator area was removed on 06/09/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II resident review for one (Resident #5) of five residents reviewed for PASRR services. The facility failed to refer Resident #5 for a Level II PASRR Evaluation upon receipt of a bipolar diagnosis. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were for 1 of 5 residents (Residents #55) reviewed for pharmacy services. 1. The facility failed to implement a system to consistently and accurately reconcile controlled medications for Resident #55's Lorazepam Oral Tablet 0.5 MG This failures could place residents at risk of not having the medication available due to possible drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, for one (Resident#34) of five residents reviewed for the storage of drugs and biologicals. The facility failed to ensure that Medications (Resident #34's Nystatin 100,000 units topical powder) was locked. This failure could result in access to medication by unauthorized persons and could result in misuse of medication.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #57) of 6 residents, reviewed for infection control. 1. LVN B failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, are reported immediately to the Administrator of the facility and to other officials in accordance with Texas law no later than two hours after the allegation is made, for 1 (Resident #2) of 6 residents reviewed for abuse and neglect in that: 1. LVN A failed to report the allegation of abuse to facility's abuse coordinator, Administrator, when Resident #2 alleged that LVN A punched her on the shoulder(date unknown). These failures placed residents at risk of ongoing abuse, physical and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #21, #35, #38, #48) of 8 residents reviewed for infection control and 2 of 2 medication rooms reviewed for infection control. Facility failed to ensure CMA F performed hand hygiene before and after checking Resident #21 blood pressure before touching pitcher of water and administering medication to Resident #21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for two (hallways F and H) of two hallways reviewed for pest control,. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This could place residents at risk for an unsanitary environment.

Inspectors wroteBased on record review, observation and interviews, the facility failed to provide for residents who are unable to carry out activities, the necessary services to maintain good grooming and personal hygiene for 2 (Resident #38 and #33) of 10 residents observed for assistance with ADL's, in that: Resident #38 had long fingernails and Resident # 33 had unkept beard, flakey skin, long, dirty fingernails and toenails. This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care and risk for unsanitary nail care and feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation and interview, the facility failed to implement procedures that address and monitor a safe storage and handling of medication that can be altered by exposure to improper temperatures, light, or humidity for 2 of 2 medication rooms reviewed for storage of drugs and Biologicals. Facility failed to maintain a safe working refrigerator in Medication room [ROOM NUMBER]. Refrigerator temperature in Medication room [ROOM NUMBER] was 56 degrees Fahrenheit inside the refrigerator. Facility failed to ensure 2 of the 3 ceiling lights in Medication room [ROOM NUMBER] worked and 3 of the 4 ceiling lights in Medication room [ROOM NUMBER] worked to provide sufficient lighting. These failures could cause medications not to be stored at proper temperatures and other appropriate environmental controls to preserve their integrity.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and supervision. CNA A failed to ensure Resident #1 was appropriately supervised while toileting, resulting in Resident #1 falling from the bedside Commode on 01/16/2024. This failure could affect residents by placing them at risk for discomfort, pain, and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #60) of ten residents reviewed for limited range of motion or therapy services. The facility failed to complete the physical, occupational, and speech therapy evaluations for Resident # 60 after completion of her therapy screen that indicated these evaluations were needed. This failure could place residents at risk for a decline in range of motion, decreased mobility and a decline in physical capabilities.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure labeling and dating of refrigerated food items. These failures could affect the residents who ate food from the facility's only kitchen by placing them at risk for food borne illness.